- Date
- February 23, 2019, 12:39 local (18:39 UTC)
- Place
- Trinity Bay, TX
- Injuries
- 3 fatal
- Damage
- Destroyed
- Phase of flight
- Enroute
- Aircraft
- N1217ABoeing 767
- Defining event
- Enroute-descent: Loss of control in flight
- Weather
- Instrument (IMC) · Day
- Status
- Completed · report August 4, 2020
- Report
- Board-adopted at Board Meeting
- Investigation class
- Class 1
- NTSB office
- Major Investigations Division
- Safety recommendations
- Yes
- FAA report
- 20190223013239A
- Case key
- 99013
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
The inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain's failure to adequately monitor the airplane's flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry's selection and performance measurement practices, which failed to address the first officer's aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration's failure to implement the pilot records database in a sufficiently robust and timely manner.
Findings · 12
NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.
Sequence of events
The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.
Analysis
The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-20/02. On February 23, 2019, at 1239 central standard time, Atlas Air Inc. flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer, and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport, Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH.
Factual narrative
The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-20/02. On February 23, 2019, at 1239 central standard time, Atlas Air Inc. flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer, and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport, Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH.
Aircraft
- Registration
- N1217A
- Reported as
- Boeing 767 (375)
- Category
- Airplane
- Serial number
- 25865
- Built
- 1992
- Engines
- General Electric CF6-80C2B6F, 24,995 horsepower, turbo fanGeneral Electric CF6-80C2B6F, 24,995 horsepower, turbo fan
- Damage
- Destroyed
- Flight
- Part 121
- Operator
- Atlas Air
- Registered owner
- Andromeda Leasing I Llc
- Airworthiness certificate
- Standard, Transport
- Departed
- KMIA · Miami
- Destination
- KIAH · Houston, TX
- Flight plan
- IFR
- Airport
- KIAH · George Bush Intercontinental
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew · 3
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 60
- Injuries
- Fatal
- Certificates
- Airline transport, Flight instructor
- Airplane ratings
- Single-engine land, Multi-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, With waivers/limitations
- Seat
- Left
- Flight hours
- 11,172 total · 1,252 in this make and model · 4,235 as pilot in command · 100 in the last 90 days · 34 in the last 30 days · 2.4 in the last 24 hours
- Role
- Co-pilot
- Age
- 44
- Injuries
- Fatal
- Certificate
- Airline transport
- Airplane ratings
- Single-engine land, Multi-engine land
- Medical
- Class 1, With waivers/limitations
- Seat
- Right
- Toxicology
- Performed
- Flight hours
- 5,073 total · 520 in this make and model · 1,237 as pilot in command · 106 in the last 90 days · 34 in the last 30 days · 2.4 in the last 24 hours
- Role
- Pilot-rated passenger
- Injuries
- Fatal
- Certificates
- Airline transport, Flight instructor
- Airplane ratings
- Single-engine land, Multi-engine land
- Medical
- Class 1, Without waivers/limitations
- Toxicology
- Performed
Weather
- Conditions
- Instrument (IMC) · Day
- Observed at
- KIAH, 41 nm away
Docket · 78
The files NTSB released with the investigation on December 19, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.5 GB in all.
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.